Much of midwifery is prevention of problems of pregnancy before they arise. Midwives help expectant mothers to have normal, healthy births via nutrition, herbs, exercise, vitamins, education and self responsibility.
Normally, care begins at the time of first telephone contact, often before my clients have met me in person and actually committed to choosing me as their caregiver. If necessary, I provide suggestions for nausea relief, nutritional advice, etc., prior to an introductory visit.
Most frequently, routine prenatal care begins in the first trimester. During this period and up until 28 weeks of pregnancy, my clients come for prenatal visits once a month (unless there are indications of a problem). From 28 weeks to 36 weeks, my clients come for prenatal visits every two weeks. At 36 weeks I do a home visit and my clients begin coming for prenatal visits every week until delivery.
If problems arise at any time during pregnancy, visits will normally be scheduled as often as necessary (i.e., more frequently than the normal schedule).
I do postpartum visits in the home one day and three days after delivery. I do postpartum visits in my office at one week, three weeks, and six weeks after delivery — at which time my postnatal care is normally terminated.
For my "average" client this means I do 14 prenatal visits, 3 home visits, and 3 other postpartum visits for a total of 20 visits.
My initial home visit is used to make sure that clients have understood and followed my instructions, obtained home birth supplies, and have a clean and safe environment for the new baby. I estimate time and distance from my office to the client’s home and give the clients instructions to call me especially early in labor, if it might take me considerable time to drive to their home. This initial visit also gives me a chance to meet other family members, gives the couple a chance to get used to presence of a midwife in their home, and gives us all a chance to become more closely bonded.
Since one of the joys and advantages of having a home birth is not having to "get up and go", postpartum home visits are always special for client and midwife. These visits give me a chance not only to check out mother and baby, but also to pamper the mother and to review and "debrief" the birth — which is so important for future family adjustments.
Often my clients will move from my care to physician’s care and back again, or vice versa. In addition, my responsibility and roles are now that of teacher of apprentices, peer assistant midwife to other midwives, political activist for midwifery, public spokesperson for midwifery, and member and promoter of several midwifery and birth related organizations.
(i) the antepartum period?
Initial visit usually includes (but is not limited to): (1) Obtain medical, obstetrical, family, dietary, gynecological and social history. (2) Perform physical exam, including pelvimetry and cultures as deemed necessary (PAP, Beta strep, etc.). (3) Venipuncture for routine prenatal screen — blood type, RH factor, VDRL or RPR, CBC with differential, Rubella titer, Hepatitis B screen, H.I.V. (4) Urinalysis. (5) Advise and inform client of availability of genetic screen tests, e.g., CVS, amniocentesis, alpha-fetoprotein.
Frequency of visits (if everything is normal) is once a month until 28 weeks; then every 2 weeks until 36 weeks; then every week until delivery.
These visits usually include (but are not limited to): (1) Maternal vital signs. (2) check for weight gain and presence of edema. (3) Dipstick urine for protein, glucose and nitrates. (4) Perform abdominal palpation for fundal height and fetal position. (5) Nutritional assessment and counseling regarding pregnancy, discomforts, and a discussion of various remedies. (6) Answer any questions that clients may have and deal with concerns.
Special testing: GTT at 28-32 weeks; Beta strep; hemoglobin every two months; RH antibody screen at 28 weeks with administration of Rhogam if necessary or referral to a physician, if screen is positive.
Referral to another caregiver at any time, if indicated or a second opinion is needed.
(ii) the intrapartum period?
Early labor is normally handled by phone contact. I begin collecting a history of labor, time it began, frequency, strength and duration of contractions, types of any discharge, status of membranes, fetal activity, physical condition of the mother (how much rest has she had; how long since she has rested).
First home assessment is an update of data from previous phone contacts and now includes last food eaten, blood pressure, pulse rate, temperature, emotional response to labor, abdominal palpation, fetal heart tones — evaluation and establish baseline. Ongoing care includes: blood pressure, pulse, temperature, maternal energy, nutritional and fluid intake, urinary output (ketones, glucose & protein), fetal heart tones, — at least every 30 minutes (more frequently as labor intensifies). Perform vaginal examinations as indicated (not often; not early). Support perineum. Assist in delivery. Perform immediate evaluation of mother and infant and take necessary steps. Assist in delivery of placenta. Deal with any complications. Normally all deliveries are also attended by another fully-qualified midwife (one for mother, one for infant — should problems arise). Encourage family bonding.
(iii) the postpartum period?
My postpartum schedule has been mentioned above. The first visit (after 24-48 hours) is in the clients home. At this visit the evaluation of the mother includes (but is not limited to); (1) Vital signs (B/P, pulse, temperature). (2) Fundus/lochia. (3) Nutrition and elimination. (4) Perineum. (5) General well being. (6) Family adjustment.
Evaluation of the infant includes (but is not limited to): (1) Temperature, pulse and respiration. (2) Cord. (3) Skin (color, hydration, rashes). (4) Lungs. (5) Breastfeeding (is the baby latching on, sucking ability and frequency). (6) Sleep/waking patterns. (7) General well being. (8) Weight. (9) Elimination. Instructions for care of mother and baby are reiterated.
Subsequent visits include the above checks. In addition, neonatal screen [PKU] is done at next day and at one week. Mother is continually checked for proper healing and recovery. Breasts are checked and monitored. Baby is checked for weight gain, cord healing, skin care, elimination, feeding, sleep/waking patterns, appropriate physical development, adjustment to life and family.
At six weeks PAP smear is performed. Contraception is discussed. Issues of family support are discussed and verified. Availability for additional contact, consultation and advice is reinforced.